To paraphrase Bill Gates: “The purpose of humanity is not just to sit behind a counter and do things. More free time is not a terrible thing.”
I have innovated. I developed a mutation assay. I discovered that vacuum ultraviolet light from excimer lasers is safe to use on human tissue. I invented an imaging device to detect burn wound depth and discovered the best laser to debride burn wounds. I invented a laser-based treatment for acne. I developed and patented an online gamified collective intelligence solution to identify dermatology images. I have participated and published as a clinician in numerous population health studies. I’ve got a few more things that I want to build and do based on my four years of medical school education, eight years of post-medical school residency and fellowship training in internal medicine, dermatology and cutaneous surgical oncology and two decades of clinical practice. Ideas for innovation arise from experience as a clinician-physician. We physician-clinicians care for patients, use all our senses, and our minds to recognize problems and apply solutions to improve the value (outcomes/costs) of preventive, medical, surgical or palliative outcomes. One needs to spend only a few hours in the basement stacks of Harvard’s Countway Medical Library to recognize the speed of physician-clinician led medical innovation which has in many ways dwarfed Moore’s Law.
For physician-clinician innovation to occur, doctors need extra-hours to work on innovative projects. Clinician-physicians working alone or with others often sacrifice family and friends to accomplish meaningful innovation, but the pay-off intrinsically for the physician and extrinsically for society and patients has been worth it. Impediments to physician-clinician led innovation has devolved during the last five years that are robbing continued progress against diseases and optimized preventive, medical, surgical and palliative care outcomes. The gift of giving clinicians time to gaze, dream and work together to apply the art and sciences of medicine towards the advancement of health care innovation has been stolen by electronic health records (EHR) and insurance company prior authorization (PA) rationing industries.
When EHRs were first introduced, health information technology seemed like a sound idea. Patient personal medical health information, labs, photos as well as physicians’ assessments and plans would be inputted into interoperable EHRs by physicians around the nation. The EHR in return would tabulate and reveal individual and aggregated data from interoperable EHRs according to all medical chart variables resulting in optimized preventive, medical, surgical and palliative outcomes and costs as well as improved clinical safety for patients and clinical efficiency for their physicians. We now know, despite federal law forcing American physicians to lease EHRs plus an additional $35 billion in taxpayer subsidies poured into the EHR industry — none of the assumed clinical advantages of EHRs have reached fruition. Blockchain or FHIR type decentralized interoperable encoded population health benefiting patients and physicians isn’t happening because optimizing data value equals outcomes/cost solutions are proprietary to industry and may diminish the earnings of the health insurance, pharmaceutical, medical malpractice, hospital, and EHR industries.
Another major unintended consequence of the government forcing physicians to use EHRs has been the shift of physician-clinician work, financial resources and time away from direct patient care and innovation into manual data entry. A recent study published in the Annals of Internal Medicine revealed that for every hour a physician spends in direct patient care the physician must perform two hours of EHR data entry. A similar study by the AMA reveal that the physicians EHR data entry tasks often follow the physician home into the late evening hours (pajama time) leaving little time for extra-clinical activities such as family, friends and continuing medical education or innovation. Yet, not one EHR company in America will be transparent and reveal its physician time-motion EHR use data to refute the damning published research. Most patient personal health information, lab data and images entered by physicians (who pay the EHR companies for the privilege of entering data) are sold by the EHR companies to ancillary health care companies but not tabulated, aggregated and returned to physicians or patients to improve outcomes/costs.
With little or no extra time for extracurricular activities beyond their practices and inputting data for sale by the EHR companies, there can be little physician-clinician innovation on any kind of translatable scale.
In addition to the EHR industry, another time drain has devolved to interfere with the ability of the physician-clinicians to innovate. Until recently, physicians would use their clinical intelligence based on years of training, continuing medical education and clinical experience to optimize preventive, medical, surgical and palliative outcomes and costs for their patients and their families. Physicians perform histories and physical examinations often resulting in prescriptions for medications, diagnostic orders, specialist referrals or recommended treatments to optimize prevention, medical, surgical and palliative outcomes for patients and their families. This science of the physician-patient interaction combined with the art of empathy is the essence of what doctors do.
Today, most private health insurance corporations ration and interfere with physicians diagnostics and treatment decisions via a health insurance industry solution termed, “prior authorization” (PA) to enhance insurance company profits. Prior authorization forces millions of patients and their physicians daily to spend hours daily manually completing multiple pages of paper or internet forms for re-submission to a non-physician insurance industry bureaucrat who — after days, weeks or months of delay — decides if the physicians recommended diagnostics or treatments for his or her patient will be reimbursed or allowed by the health insurance company.
Most often, health insurance corporate PA decisions against the patients and against medical advice are not made by a board-certified physician who performs a history or physical exam or discussion with the targeted patient. There is not a patient or physician in America with private health insurance who hasn’t experienced the demeaning and potentially dangerous task of manual PA health care rationing of medications, diagnostics or treatments. What’s good for the patient based on the physician’s assessment may be harmful to the earnings of the insurance or pharmaceutical benefits company, and thus PA rationing was spawned.
Spending tens of hours each week on the clinically valueless and inefficient tasks of data entry into EHRs and attempting to override insurance company prior authorization rationing leaves no time for the physician-clinician to innovate or iterate advances in medicine. The future of health care and the value equals outcomes/costs of health care in America will continue to be damaged by the EHR and health insurance industries by inhibiting clinicians-physicians from participating in medical innovation and clinical translation in America.
Howard Green is an internal medicine physician.
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